"The only physician in a 17.000 inhabitants town asks for a MEDEVAC. The local doctor describes a stable case of a 40y man with chronic hypertension, who presented with a 12-hour long chest pain worsening at exercise, likely to have an unstable angina. He lives in the jungle, almost 6-hour by boat from the point of care. The doctor had nothing else besides a normal CBC and an X-ray with enlarged cardiac silhouette. The patient should go to the state capital, 1100Km far, 3-hours journey in a non-pressurized, non-intensive care airplane. This plane is usually designed for passenger transport, but on demand it is redefined for MEDEVAC. ICUs are usually set up in jet planes, but most airstrips in Amazon basin do not support them and many places are only reached by military aircrafts.
The patient was on a stretcher, no Oxygen mask, no oximetry, no IV access, no monitoring. The nurse immediately provided peripheral access in both arms (I had an intraosseous needle, in case we need...) and I quickly checked vital signs, SpO2 92% in room air. We placed a nasal catheter and prepared him to lift onboard.
At that moment, the city health secretary approached us: "Hi. We have another patient to take to the capital, a young male 25y, suspected meningitis, no seizures, conscient, antibiotics started 1 hour ago." Patient's mother shouts: "This airplane is his only chance to live."
Dilemma: We had a mission: MEDEVAC a cardiac patient. No other place, no backup support, no team for 2 potentially critical patients. Engines on. Pilots asking: "Hey, doc, is it safe for us to carry a patient with meningitis here?". The nurse terminates the drama: Hey, Tennent, No PPE for infectious diseases, once the patient was supposedly just cardiac."
They all stare on me, claiming for a veredict. I had a dilemma, but no decision yet. Deciding Decision-making process is always a difficult task for most professionals, but military HCP in charge for critical patients or facing limited resources are especially prone to face harder times, mainly due to ethical issues involved.
I decided not to take both patients. I stated I would fly the cardiac one, whom we came prepared for, who looked more unstable and had confirmed facility to receive him at the destination."
Source: Report from course participant's personal experience
– What do you think about the doctor's decision?
– How should military HCP manage and balance political issues and clinical decision-making process in point-of-care settings?
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